overview of outcome data of potential meditation training for

MILITARY MEDICINE, 176, 11:1232, 2011

1232 MILITARY MEDICINE, Vol. 176, November 2011

INTRODUCTION The high incidence of post-traumatic stress disorder (PTSD), suicides, and other adverse events in returning Operation Iraqi Freedom/Operation Endurance Freedom veterans 1,2 has made soldier (and family) resilience, defi ned as “the ability to meet challenges and to bounce back after diffi cult experiences,” 3 a priority for the Army. The mandatory Comprehensive Soldier Fitness (CSF) program requires soldiers to self-administer the Global Assessment Tool (GAT) and then segue online into Resilience Training (RT) currently comprising vignettes and didactic material. As the CSF is new and has as yet no clear “gold standard” metric for resilience in soldiers (nor does most published research 4 ), data prospectively confi rming the effi cacy of current RT are not yet available. 5,6 Modalities for future training are in development. In years to come, as sol-diers continue to take the GAT and then select training, it is appropriate that the training opportunities would not be lim-ited to a recapitulation of perhaps previously mastered edu-cational material and would include tools for development of high-level wellness and performance.

Decisions regarding such training will need to be based upon inferences from the body of research that does exist regarding similar or related areas in the fi eld of self-development. This analysis assumes that there are direct relationships between resilience and parameters such as enhanced physical health, freedom from anxiety and distress, improved social integra-tion and better family and workplace relationships, decreased substance abuse, and the other metrics reviewed herein. It fur-ther assumes that any training added to current RT will be evidence-based and amenable to execution in an operational environment.

All such tools or activities should be portable and incon-spicuous (as practices that invite stares are unlikely to be acceptable to soldiers). For example, although no one should

expect soldiers to practice eyes closed techniques while they need to pay attention to their environment, any such tech-nique should be possible to practice in “downtime” even while wearing cumbersome equipment, perhaps while in a vehicle, airframe, or austere setting. It should not require privacy, the cooperation or service of another person, nor further in-theater support or training. The modality should produce desired perceptible results promptly; training to standard should not add an undue burden of training time.

Interpreting data from the fi elds of cognitively oriented self-development and resilience is a challenge. MEDLINE searches for resilience and self-development do not reveal many controlled studies. 7,8 This article focuses on the arena of eyes closed seated meditative techniques, widely known and studied as “stress management” or “relaxation techniques.”

Interpreting data from meditation and relaxation also is not simple. Although experts in their fi elds (including abbots of monasteries and leaders of ashrams) readily distinguish the procedures, objects, contents, and goals of their meditation practices, 9 many researchers are indiscriminate in combining data from a number of different techniques; the value of their conclusions is at best unclear. 10–12 In fairness to those authors, some meditative or relaxation approaches are quite fuzzy in differentiating their procedures from each other.

Comparison of both electroencephalographic and fMRI studies 13–15 reveals that those techniques so compared, insight meditation, Vipassana or mindfulness meditation, Tibetan Buddhist “unconditional loving-kindness and compassion,” and Transcendental Meditation (TM), show characteristic and reproducible fi ndings that are readily distinguishable from one another . As one of the authors notes, “Brain patterns are a language that cuts across differences in cultures, worldviews, and emotionally vested terms that can cloud consideration of different meditation practices”. 13

This review demonstrates that different techniques from different traditions differ in procedure, have different effects

Overview of Outcome Data of Potential Meditation Training for Soldier Resilience

COL Brian Rees , MC USAR

ABSTRACT In order to identify potential training to enhance comprehensive soldier fi tness, this analysis searched MEDLINE via PubMed and elsewhere for 33 reasonably signifi cant modalities, screening over 11,500 articles for rel-evance regarding soldier resilience. Evaluation of modalities that are exclusively educational or cognitive/behavioral in nature is deferred. Using the volume and quality of research over 40 parameters distributed among the fi ve domains of resilience (physical, emotional, spiritual, social, and family life), these data allow culling of most of the meditative modalities and discrimination among the remaining techniques. The resulting order of merit is Transcendental Meditation, mindfulness, and progressive muscle relaxation. Transcendental Meditation, mindfulness, and progressive muscle relax-ation, in that order, have the most supporting data. Fortuitously, they also represent a cross section of the domain of tech-niques regarded as meditation, stress management, or relaxation, with three very different mechanisms of action. They are suitable potential options for improving soldier resilience.

63rd Regional Support Command, Moffett Field, CA 90435.

Dow

nloaded from https://academ

ic.oup.com/m

ilmed/article/176/11/1232/4345305 by guest on 20 August 2022


MILITARY MEDICINE, Vol. 176, November 2011 1233

in brain and body, and have quite distinguishable clinical and psychological outcomes. These outcomes suggest some to be more suitable for enhancing soldier resilience than others.

METHODS This analysis used the following steps:

(1) Identifi es assumptions and screening criteria regarding training modalities for soldier resilience.

(2) Through MEDLINE searches and informally through contacts in the Army, identifi es signifi cant candidates for training modalities ( Table I ).

(3) Eliminates candidates who do not meet screening criteria.

(4) Searches MEDLINE via PubMed to determine the vol-ume of research done on the candidates ( Table II ).

(5) Eliminates those candidates without an adequate base of data to support them.

(6) Via searching MEDLINE as well as visiting Web sites for techniques known to be under consideration, com-poses a list of outcome parameters relevant to soldier

resilience that have been used (and published) to study the top candidates.

(7) Synopsizes the studies; reviews or meta-analyses that directly compare any of the selected modalities to one another are discussed, other studies listed in Table III .

(8) Discusses the fi ndings and constructs an order of merit list for the modalities that survived scrutiny.

(9) Makes recommendations based upon the fi ndings.

RESULTS

First Round Cuts as a Result of Feasibility Issues Three of the modalities listed in Table I do not meet the “aus-terity” criteria listed in the introduction and thus do not make the fi rst cut: pranayama includes breathing exercises that would be too conspicuous on an airplane or in an open bay; hatha yoga requires loose fi tting clothing and a fl at comfort-able surface (no go while wearing body armor, or in a vehicle, or living and sleeping in the dirt); and reiki requires the thera-peutic touch of a reiki practitioner.

TABLE I. List of Training Approaches Initially Considered (Alphabetical)

1 Battlemind2 Biofeedback3 Biofeedback (EMG)4 Boot Strap /STARS/Stress Gym Interventions5 Compassion Training6 Concentration7 Corporate Meditation (Thornton)8 Kripalu Meditation9 Mantra Meditation (Other Than TM)

10 Meditation (Any Other, Not Otherwise Specifi ed)11 Mindfulness Based Mind Fitness Training (by Jha)12 Mindfulness Based Stress Reduction (by Kabat-Zinn)13 Mindfulness Meditation (AKA Vipassana or Insight)14 One Shot-One Kill15 Penn Resiliency Program16 Pranayama17 PMR18 Qi Gong19 RR (Benson)20 RR Meditation21 Relaxation (other)22 Reiki23 Samurai Mind Training24 Soft Belly Meditation25 Super Calm Meditation26 Tibetan Buddhist Meditation27 Total Awareness28 Transactional Analysis29 TM30 Warrior Mindfulness31 Yoga, Hatha32 Yoga Medics33 Zen Meditation

TABLE II. Volume of Research

Training/Modality

Number of Studies Found in PubMed

1 Biofeedback 6,0832 TM 1,7213 PMR 7614 Transactional Analysis 4815 Mindfulness Meditation 3636 Concentration Meditation 2317 Mindfulness-based Stress Reduction

(Kabat-Zinn)173

8 Biofeedback (EMG)/Stress Related 1,396/1459 RR Meditation 102

10 Qi Gong (Chi Gung ~ Pranayam and/or Mindfulness)

90

11 Zen Meditation 6012 RR (Benson) 5813 Mantra Meditation (Other Than TM) 1014 Tibetan Buddhist Meditation 915 Total Awareness (Mindfulness or TM) 816 Compassion Training (Military, Other

Than Nurse Training)7

17 Penn Resiliency Program 618 Battlemind 3, Plus Those

Not Yet Published19 Boot Strap/STARS/Stress Gym

Interventions3

20 Mindfulness-based Mind Fitness Training (Jha)

2

21 Kripalu Meditation 122 One Shot-One Kill 123 Warrior Mindfulness 124 Corporate Meditation (Thornton) 025 Samurai Mind Training 026 Soft Belly Meditation 027 Super Calm 028 Yoga Medics 0

Dow


ic.oup.com/m




Second Round Cuts as a Result of Defi ciencies in Evidence-based Outcome Data Starting with the least researched, this analysis eliminates yoga medics, super calm meditation, soft belly meditation, samurai mind training, corporate meditation, warrior mindful-ness, kripalu meditation (assuming that the previous three are separate from other mindfulness discussed below), compas-sion training, Tibetan Buddhist meditation, and mantra medi-tation other than TM. These approaches may have value, but it is beyond the scope of this article to discern what that value might be. If they are to be included in the training modules for soldier resilience, inclusion would have to be for reasons other than evidence-based outcome data.

Nonspecifi c relaxation and meditation cannot be distin-guished from more specifi c modalities and thus are not con-sidered separately.

The three categories of mindfulness above, as well as the categories of both concentration and Zen meditation, 16 are fairly indistinguishable; searches for one or the oth-ers often identify the same articles, and the methodologies appear to overlap, with perhaps some proprietary differences opaque to this analysis. Qi Gong references variably describe both pranayama and mindfulness; “total awareness” arti-cles refer to either TM or mindfulness. Qi Gong and total awareness are cut. Although there may be signifi cant differ-ences among mindfulness techniques, they are not yet fully elucidated; for purposes of this evaluation, all mindful-ness, Zen, insight meditation, Vipassana, and concentration, whether done with eyes closed or executed during activ-

ity or both, are retained but rolled up into a single category: mindfulness.

The Army’s Battlemind Training (the precursor to RT) has been studied as employed after the combat stress event. 17,18 The Penn Resiliency Program (PRP) 19–22 and the One Shot-One Kill, Boot Strap, STARS, and Stress Gym 23–29 interventions have not been compared to one another; information is insuffi -cient for this review to distinguish among these programs nor to compare them meaningfully to the meditative techniques considered. This analysis assumes that online behavioral and coping skills RT such as that currently available through the Army Knowledge Online link of the CSF program and face-to-face training such as the PRP (or its cousins, progeny, or successors) are here to stay, but will not be further discussed in this article.

The proponents of relaxation response (RR), a technique derived from TM, contend that stress management and relax-ation and meditation techniques are all essentially the same. As a result of that assumption, they often borrow data freely from other specifi c techniques and attribute the results to the RR. 30 This contention is confusing and is not supported by neuroimaging data, 13 nor by meta-analyses or compara-tive studies. 31–33 But since its proponents also claim it can be learned from a book and is thus simple and inexpensive, it is tempting to include RR in further discussion. Three consid-erations militate against inclusion. First, its core assumption (of universal equivalence of techniques) appears unredeem-able. 13,31 Second, by its advocates’ own assertions, it is deriv-ative: it brings nothing new or different to the fi ght. Third, available data demonstrate that it is inferior in its outcomes, whenever data exist to compare, 31–33 to at least one other tech-nique (TM) under consideration. For these reasons, RR is eliminated.

Biofeedback does not make the cut. Although it has thou-sands of citations, they mostly have to do with specifi c clini-cal entities such as incontinence or tinnitus, and the studies related to stress reveal very little applicable to resilience or the types of holistic fi tness or continuous self-development objec-tives of CSF.

Transactional analysis does not make the cut; it has not been signifi cantly studied. The culling above leaves three training modalities:

mindfulness — progressive muscle relaxation (PMR) — TM —

Descriptions of the Modalities and Differentiating Brain Effects Mindfulness is traditional with some modern cognitive ele-ments; its effects are mediated by changing the interpretation of internal and environmental cues and by enhancing cop-ing skills. PMR is a modern laboratory-derived technique, which promotes muscular and subsequent mental relaxation. TM is a traditional technique, effecting changes in physical,

TABLE III. References for the 3 Modalities Relevant to CSF Domains

Domain TM Mindfulness PMR

Physical Hypertension 64–69 — — CV Disease and Risk 70–76 — — Tobacco, Alcohol, and

Substance Abuse83–87 37,77–82 88

HPA Axis, Lipids, Hormones, and Aging

90–99 89 —

Stress Reactivity and Reaction Time

46,58,100–103 — —

Pain 113,114 106–112 104,105Emotional and Spiritual Intelligence, Cognition,

and Academics102,115–120 121–123 —

Creativity and Morals 62,124–132 — — Anxiety and Depression 151–154 38,133–148 149,150 Sleep, Attention defi cit

hyperactive disorder, and PTSD

157–159,161 155,160 156

Social and Family Marital and Family 162,163 — — Discipline and Legal 164–169 — — Leadership, Effi ciency,

Tolerance, Social and Workplace Integration

170–183 — —

Dow


ic.oup.com/m




psychological, and social health and behavior through changes in brain (and related physiological) functioning.

Mindfulness A variety of practices are fall under the rubric of “mindful-ness,” which is commonly defi ned as a:

…dispassionate, non-evaluative and sustained moment-by-moment awareness of perceptible mental states. This includes continuous, immediate awareness of physical sensations, perceptions, affective states, thoughts, and imagery. Mindfulness is non-deliberative. It merely im -plies sustained paying attention to mental content without thinking about it, comparing or in other ways evaluating the ongoing mental phenomena that may arise during periods of practice. 34

Mindfulness meditation is described as a systematic pro-cedure to develop enhanced awareness of moment-to-moment experiences. Mindfulness can include at least two meditation practices:

with eyes closed: attention on breath — with eyes open: dispassionate observation of body, —senses, and environment. This meditation involves inten-tion or directing of attention to physiological rhythms, inner thoughts, sensations, or outer objects.

Though derived from a Buddhist background, mindfulness is not a religion, does not require faith, and is compatible with any religious tradition.

Mindfulness is negatively correlated with resting activity in the amygdala bilaterally, as opposed to depressive symptoma-tology positively correlated with amygdalar activity. 35 During an “affect labeling” task of dispositional mindfulness, func-tional magnetic resonance imaging reveals widespread pre-frontal cortical activation and reduced amygdalar activity. 36 A review of 7 “mainly poor quality studies” of Vipassana mindfulness included 3 with neuroimaging results, showing activation of prefrontal and anterior cingulate cortex. 37 Patients suffering from social anxiety disorder completing a course in mindfulness-based stress reduction (MBSR) showed reduced amygdalar activity and “increased activity in brain regions implicated in attentional deployment” 38 during one of two mind-fulness tasks; healthy subjects had increased regional gray matter density after the MBSR course. 39 A review of Zen meditation showed an increase in alpha and theta waves frontally. 16

Per a mindfulness instructor contacted by this author, a course in mindfulness was to include six sessions, a full day retreat and then a fi nal session, with ~15 hours of contact time. As of 2008, the cost was $100 an hour per person or $1,500 for each individual. This course and fee structure may or may not be typical. Per its website, MBSR in 2010 had fees from $450 to $600 depending upon income.

Mindfulness is taught by many psychologists, Masters of Social Work, and other individuals. Some programs (such as MBSR) are fairly standardized. There is no umbrella organi-

zation that determines or enforces a standard for all mindful-ness practice or instruction.

Progressive Muscle Relaxation Descriptions of PMR abound. That in Wikipedia 40 is typical:

… a technique of stress management developed by American physician Edmund Jacobson in the early 1920s. 41 Jacobson argued that since muscular tension accompanies anxiety, one can reduce anxiety by learning how to relax the muscular tension….

PMR involves alternately tensing and relaxing the mus-cles. 42 A person practicing it may start by sitting or lying down in a comfortable spot and taking some deep breaths, and then he or she will proceed to tense, then relax, groups of mus-cles in a prescribed sequence…. The effect of the tension–relaxation sequence is to cause deeper relaxation than would be achieved by simply attempting to relax.

In theory, one can practice PMR on one’s own after simply reading some instructions, with perhaps some guidance as to which muscles to involve in what order. PMR also is commonly taught by therapists from many disciplines, including physical and occupational therapists. Fees for such services are variable.

Transcendental Meditation TM is an effortless purely mental technique, practiced for 15 to 20 minutes twice daily, seated with eyes closed, requiring no other changes in lifestyle. It comes from the Vedic tradi-tion of India and was popularized over the last 50 plus years by the late Maharishi Mahesh Yogi. Like mindfulness, it is not religious in nature. It uses what proponents describe as the “natural tendency of the mind” to move toward greater enjoy-ment and charm, effecting “automatic self-transcending” 43 ; during the practice, the mind easily moves toward subtler levels of thought and can “transcend” thinking altogether, allowing the mind and body to experience “restful alertness,” a state of unique and salubrious mental and physiological functioning.

Physiologically, restful alertness is associated with a state of rest, as refl ected in decreased metabolism, respiration rate, and blood fl ow to the limbs, decreased sympathetic activity, 44 and increased mental alertness, as refl ected in higher frontal electroencephalogram (EEG) coherence. 45 This experience allows the body to remove effects of previous stressors and to be more resilient to current stressors. 46

Restful alertness is associated with both activation of atten-tional systems and deactivation of thalamic input circuits in a positron emission tomography study 15 and higher frontal EEG coherence—a measure of functional connectivity. 47,48 The expe-rience and associated brain state of restful alertness during TM practice is refl ected in long-term changes in brainwave patterns during tasks outside of meditation practice—broadband frontal coherence, normally seen during TM practice, is progressively seen during challenging tasks with regular TM practice, 47–49 enhancing frontal executive functioning. 50 Multiple studies

Dow


ic.oup.com/m




have documented characteristic EEG fi ndings in TM; within the practice, power and alpha coherence increases, 48,50–53 coher-ence which increased within 2 weeks of practice. 54

TM is proprietary and standardized. All TM instruction is performed only by teachers certifi ed to teach TM by the global TM organization. The course of instruction is always the same, involving fi ve sessions in the fi rst week followed by optional “checking” weekly for the fi rst month and monthly for the fi rst year. As of early 2011, the U.S. course fee is $1,500 per person, with a discount to $1,200 per person for groups (fam-ily rates, military rates as low as $750, and low-income schol-arships also exist). Follow-up (“checking”) is included in the course fee, lifelong and worldwide, as frequently as may be desired by the TM meditator.

Head-to-Head Comparisons and Meta-analyses

Comparing PMR and TM

In the fi rst of two prospective randomized controlled trials (RCTs) of hypertensive African-Americans, the TM group had signifi cantly decreased blood pressure compared to the PMR group and to usual care in a 3-month study of 150 subjects. 55 These fi ndings were replicated in the second RCT, a 1-year-long study of 127 subjects. The TM group decreased its use of anti-hypertensive medication; the PMR group increased its use. 56

Comparing PMR and Mindfulness

In this 1-month RCT, 83 distressed college students were randomized to mindfulness, “somatic relaxation,” or a no-treatment control. Both the mindfulness and relaxation groups similarly decreased distress and increased positive mood. Mindfulness was more effective in decreasing distractive and ruminative thought behaviors than was PMR or control. 57

Comparing TM and PMR

Eighty-three African-American college students were ran-domized to TM, PMR, or “cognitive strategies.” A year later, both the TM and PMR groups were signifi cantly improved in mental health and anxiety; TM showed greater reduction in neuroticism compared to both PMR and cognitive strategies. The TM group showed increased EEG coherence compared to eyes closed, other groups did not. The TM group had faster habituation to stressful stimuli than did the PMR group. 58

Comparing TM and PMR

Older hypertensives randomized to TM, PMR, or usual care were followed for mortality for a mean of 7.6 years. The TM group had 23% less all-cause mortality, 30% less cardiovas-cular mortality, and 49% less cancer mortality than combined controls. 59

Comparing Mindfulness and TM (and RR)

Seventy-three elderly were randomized to TM, mindfulness, or RR. The TM group had signifi cantly better cognitive func-tion, mental health, blood pressure, and survival compared to the other groups. 32 Eight- and fi fteen-year follow-ups con-

fi rmed TM group superiority in both cardiovascular and all-cause mortality. 60

Meta-analysis of PMR and TM (and Biofeedback) in Hypertension

TM signifi cantly outperformed PMR (and biofeedback) in reduction of blood pressure among hypertensives. 61

Meta-analysis of TM, PMR, and Other Meditations in Trait Anxiety

In 146 studies, the effect size for TM was more than double that of the others, including placebo, PMR, and other medita-tions including mindfulness, (and non-TM mantra meditation, biofeedback, and RR). 33

Meta-analysis of TM, Relaxation, Other Meditation (Including but Not Specifying Mindfulness)

In 42 studies, the effect size for TM was 3 times that of relax-ation and other meditation in increasing self-actualization. 62

Meta-analysis of TM, PMR, and Mindfulness (and Numerous Other Modalities)

In eight meta-analyses of 597 studies of over 20,000 subjects, TM signifi cantly outperformed other modalities across a host of outcomes, including improved psychological outcomes and decreased use of cigarettes, drugs, and alcohol. 31

A review and meta-analysis of 27 studies concluded that “meditation” was more effective than progressive relaxation, autogenic training, and applied relaxation in reducing anxiety. 63

Studies of the 3 Modalities CSF Parameters The Army’s CSF Program recognizes fi ve domains of life that require fi tness/wellness for the soldier to function optimally: physical, emotional, spiritual, social, and family. Table III cites the extant literature regarding the three selected techniques. 37,38,47,58,62,64–183

DISCUSSION Discussion is along four axes: effi cacy, acceptability, quality control, and cost.

Effi cacy Limitations to the determination of effi cacy are at least three: there may be signifi cant distinctions between resilience, as desired by the U.S. Army, and the parameters cited in this evaluation; mindfulness and more so PMR have not been studied at all in some CSF domains ( Table III ); and the stud-ies cited were almost universally not performed on American soldiers.

Of the three modalities, mindfulness, PMR, and TM, avail-able data support TM as the most effi cacious in virtually all the outcomes studied to date. 31 TM has the greater volume of supporting research (with the exception of a larger vol-ume of studies on mindfulness and pain) and more high-quality studies (prospective randomized controlled design) than the other two approaches. Virtually all the meta-analyses and

Dow


ic.oup.com/m




comparative studies show greater effect sizes for TM in con-ditions from hypertension 56,60,61 to anxiety 33 to mortality, 32,60 in populations varied in age, ethnicity, and nationality.

Confl icting data inhibit conclusions regarding the relative effi cacy of mindfulness versus PMR. PMR may reduce anxi-ety 63 and substance abuse 88 ; the physiological underpinning of the cognitive improvements is as yet undetermined. 88 Some reviewers conclude that mindfulness has effi cacy in stress reduction 140,141,184 and a variety of other health issues. 139 Others conclude that it does not have a reliable effect on depres-sion or anxiety 145 and has equivocal fi ndings for sleep distur-bance 155 and that the paucity of research does not support a strong endorsement of this approach. 185

Acceptability There are no data to indicate that any one of the modalities would be more or less acceptable to soldiers than the others.

PMR is lab-generated with no elements from a non-Western culture. It may be more attractive to soldiers with muscular tension issues or those not comfortable with any form of “meditation.” PMR appears to be simple and have a modest time requirement and gentle learning curve although one review of 29 studies with various psychophysiological outcomes indicated that its effects are greater with more ses-sions, individualized treatment, and greater treatment dura-tion. 186 There is no evidence of poor acceptability.

TM is unabashedly traditional. Professional teachers describe its origins in the Vedic tradition of India when intro-ducing prospective students. Personal instruction in TM is always done on a one-to-one basis, in private. Also, it is pro-prietary; students are asked to keep their instruction private. In addition, “dabbling” in TM is actively discouraged. Teachers ask prospective students to commit to make and take the time to be regular in their twice-daily practice of TM, asserting that greater effi ciency and enjoyment more than make up for the time spent meditating. These points may constitute barriers to learning TM for some soldiers. In the challenging population of psychiatric inpatients, TM was “more readily accepted with longer compliance than training in progressive relaxation or EEG alpha rhythm enhancement.” 187

The term “unique” is often used when describing TM; this term is a red fl ag for many. 188–190 TM proponents explain “unique” thusly: automatic self-transcending is an innate human capability, but there are more and less effi cient ways to reach that state, and the technique to elicit it is acquired. TM advocates quote their data and say that, by virtue of its long, many millennia-old tradition, TM is “uniquely” effi cient in bringing about that healthy style of functioning in mind and body.

Mindfulness may be somewhat between TM and PMR in the areas discussed above. It is traditional; not as overtly as TM, but more than PMR. Acceptability may be a function of local issues as mindfulness is not standardized; but at least one program demonstrated 88% of participants still meditating after 4 months. 108 In a 2009 study, mindfulness was acceptable

when added to behavioral interventions in a family-focused adolescent drug prevention program. 191 Time requirements for mindfulness may be comparable to PMR and TM. Long-term follow-up requirements have not been specifi ed.

Quality Control Mindfulness and PMR are both taught by a variety of thera-pists and counselors or in theory could be self-taught. Reliance upon qualifi ed personnel should be adequate.

TM is always taught by certifi ed TM teachers. A program of mandatory ongoing recertifi cation of instructors assures good quality control.

Cost There are no published data demonstrating any signifi cant risks associated with the practice of any of the three modali-ties. Indeed, a study by the Swedish National Health Board in 1975 found that hospitalization for psychiatric care was 150 to 200 times less common for TM practitioners than for the general population. 192 However, it is inevitable that some unfortunate young soldier who is destined to experience his or her initial psychotic break will do so soon after having been trained in one of the modalities; some stakeholders may see a cause–effect relationship where one has not been shown to exist.

Costs for TM and for mindfulness may be comparable. The cost for PMR may be less depending on the nature of contract-ing for individuals to instruct PMR.

TM has demonstrated lower health care utilization and costs. 193–198 This may make TM attractive to soldiers, fami-lies, and organizations responsible for providing their medi-cal and mental health services as the costs to society from combat-related PTSD alone are in the billions of dollars per year. 1 Mindfulness and PMR may have as yet undemonstrated benefi cial effects on health costs. The magnitude of those sav-ings, if any, is unknown.

RECOMMENDATIONS

(1) Include one or more of the three modalities in the menu of training options for the promotion of soldier resilience, in this order: TM, a form of mindfulness, and PMR.

(2) After proper Institutional Review Board vetting, ran-domize soldiers in unit(s) about to deploy to be trained in either one of the three recommended modalities or in a “usual care” control group. During and after deploy-ment, measure performance on the GAT, the incidence of PTSD, Uniform Code of Military Justice actions, administrative discharges, divorces, substance abuse, and other physical, psychological, and behavioral health endpoints.

(3) Adopt or develop metrics adequate to measure antici-pated high-level growth in the domains of CSF (phys-ical, emotional, spiritual, family, and social) as a result of this training; alternatively, the GAT could be

Dow


ic.oup.com/m




expanded and revalidated to accomplish this. Study a selected subpopulation with more in-depth physiologi-cal and psychological tests and neuroimaging.

(4) Use the Soldier Fitness Tracker to identify the most effective of the training modalities.

(5) Adopt the “best practice”’ identifi ed by recommenda-tions (2) and (4) and disseminate throughout the Army.

REFERENCES 1. Tanielian T , Jaycox LJ (editors): Invisible Wounds of War: Psychological

and Cognitive Injuries, Their Consequences, and Services to Assist Recovery . Santa Monica, CA , RAND Corporation , 2008 .

2. Sher L , Yehuda R : Preventing suicide among returning combat veter-ans: a moral imperative . Mil Med 2011 ; 176 (6) : 601 – 2 .

3. Woll P : Resilience 101: understanding and optimizing your stress sys-tem after deployment; workbook for veterans and service members . Available at http://www.attcnetwork.org/learn/topics/veterans/docs/Resiliance101wkbk.pdf , October 2009; accessed June 18 , 2011 .

4. McGeary D : Making sense of resilience . Mil Med 2011 ; 176 (6) : 603 – 4 .

5. US Army Medical Department. Resilience training . Available at https://www.resilience.army.mil/bhr.html , accessed December 22, 2010 .

6. Seligman M , Matthews M (editors): Comprehensive soldier fi tness . Am Psychol Special issue 2011 ; 66 (1) : 1 – 86 .

7. Steinhardt M , Dolbier C : Evaluation of a resilience intervention to enhance coping strategies and protective factors and decrease symp-tomatology . J Am Coll Health 2008 ; 56 (4) : 445 – 53 .

8. Fraser E , Pakenham KI : Evaluation of a resilience based intervention for children of parents with mental illness . Aust N Z J Psychiatry 2008 ; 42 (12) : 1041 – 50 .

9. Shear J (editor): The Experience of Meditation: Experts Introduce the Major Systems . St. Paul, MN , Paragon House , 2006 .

10. Ospina MB , et al : Clinical trials of meditation practices in health care: characteristics and quality . J Altern Complement Med 2008 ; 14 (10) : 1199 – 213 .

11. Ospina MB , et al : Meditation practices for health: state of the research . Evid Rep Technol Assess 2007 ; (155) : 1 – 263 .

12. Black DS , et al : Sitting meditation interventions among youth: a review of treatment effi cacy . Pediatrics 2009 ; 124: e532 – 41 .

13. Travis F : Are All Meditations the Same? Comparing the Neural Patterns of Mindfulness Meditation, Tibetan Buddhism practice “unconditional loving-kindness and compassion,” and the Transcendental Meditation Technique . Available at http://www.fredtravis.com/talk.html , April 2006; accessed December 22 , 2010 .

14. Lazar S , et al : Meditation experience is associated with increased corti-cal thickness . Neuroreport 2005 ; 16: 1893–7 .

15. Newberg A , et al : Cerebral Glucose Metabolic Changes Associated with Transcendental Meditation Practice. Neuroimaging Summer Confer-ence , Miami, FL , 2006 .

16. Chiesa A : Zen meditation: an integration of current evidence . J Altern Complement Med 2009 ; 15 (5) : 585 – 92 .

17. Adler AB , et al : Time-driven battlemind psychological debriefi ng: a group-level early intervention in combat . Mil Med 2009 ; 174 (1) : 21 – 8 .

18. Adler AB , et al : Battlemind debriefi ng and battlemind training as early interventions with soldiers returning from Iraq: randomization by pla-toon . J Consult Clin Psychol 2009 ; 77 (5) : 928 – 40 .

19. Cardemil EV , et al : The prevention of depressive symptoms in low-income, minority children: two-year follow-up . Behav Res Ther 2007 ; 45 (2) : 313 – 27 .

20. Cutuli JJ , et al : Preventing co-occurring depression symptoms in ado-lescents with conduct problems: the Penn Resiliency Program . Ann N Y Acad Sci 2006 ; 1094: 282 – 6 .

21. Gillham JE , et al : School-based prevention of depressive symptoms: a randomized controlled study of the effectiveness and specifi city of the Penn Resiliency Program . J Consult Clin Psychol 2007 ; 75 (1) : 9 – 19 .

22. Ralph A , Nicholson L : Teaching coping skills to depressed adolescents in high school settings . Behav Change 1995 ; (12) : 175 – 90 .

23. Lunasco TK , et al : One Shot-One Kill: a culturally sensitive program for the warrior culture . Mil Med 2010 ; (175) : 509 – 13 .

24. Cohn A , Pakenham K : Effi cacy of a cognitive-behavioral program to improve psychological adjustment among soldiers in recruit training . Mil Med 2008 ; 173 (12) : 1151 – 7 .

25. Williams A , et al : Psychosocial effects of the Boot Strap intervention in Navy recruits . Mil Med 2004 ; (169) : 814 – 22 .

26. Linkh DJ , Sonnek SM : An application of cognitive-behavioral anger management training in a military occupational setting: effi cacy and demographic factors . Mil Med 2003 ; (163) : 475 – 8 .

27. Holaday M , Smith A : Coping skills training: evaluating a training model . J Ment Health Couns 1995 ; (17) : 360 – 7 .

28. Williams A , et al : STARS: strategies to assist navy recruits’ success . Mil Med 2007 ; (172) : 942 – 9 .

29. Williams RA , et al : Stress Gym: feasibility of deploying a web-enhanced behavioral self-management program for stress in a military setting . Mil Med 2010 ; (175) : 487 – 93 .

30. Benson H : The Relaxation Response , pp 95 – 97 . New York , Avon Books , 2006 .

31. Orme-Johnson DW , Walton KG : All approaches to preventing and reversing the effects of stress are not the same . Am J Health Promot 1998 ; 12 (5) : 297 – 9 .

32. Alexander CN , Langer EJ , Newman RI , Chandler HM , Davies JL : Transcendental meditation, mindfulness, and longevity: an experimen-tal study with the elderly . J Pers Soc Psychol 1989 ; 57 (6) : 950 – 64 .

33. Eppley K , Abrams A , Shear J : Differential effects of relaxation tech-niques on trait anxiety: a meta-analysis . J Clin Psychol 1989 ; 45 (6) : 957 – 74 .

34. Grossman P , et al : Mindfulness based stress reduction and health ben-efi ts. A meta-analysis . J Psychosom Res 2004 ; 57 (1) : 35 – 43 .

35. Way BM , et al : Dispositional mindfulness and depressive symptomatol-ogy: correlations with limbic and self-referential neural activity during rest . Emotion 2010 ; 10 (1) : 12–24 .

36. Creswell JD , et al : Neural correlates of dispositional mindfulness during affect labeling . Psychosom Med 2007 ; 69 (6) : 560 – 5 .

37. Chiesa A : Vipassana meditation: systematic review of current evidence . J Altern Complement Med 2010 ; 16 (1) : 37–46 .

38. Goldin PR , Gross JJ : Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder . Emotion 2010 ; 10 (1) : 83 – 91 .

39. Holzel BK , et al : Mindfulness practice leads to increases in regional brain gray matter density . Psychiatry Res 2010 ; 191 (1) : 36 – 43 . Epub November 10, 2010.

40. 2010 Mar http://en.wikipedia.org/wiki/Progressive_muscle_relaxation; accessed April 26, 2010.

41. Jacobson E : Progressive Relaxation . Chicago , University of Chicago Press , 1938 .

42. Wolpe J , Lazarus AA : Behavior Therapy Technique . New York , Pergamon Press , 1966 .

43. Travis F , Shear J : Focused attention, open monitoring and automatic self-transcending: categories to organize meditations from Vedic, Buddhist and Chinese traditions . Conscious Cogn 2010 ; 19 (4) : 1110 – 8 .

44. Dillbeck MC , Orme-Johnson DW : Physiological differences between transcendental meditation and rest . Am Psychol 1987 ; 42 (9) : 879 – 81 .

45. Wallace RK , Benson H , Wilson AF : A wakeful hypometabolic physi-ologic state . Am J Physiol 1971 ; 221 (3) : 795 – 9 .

46. Orme-Johnson DW : Autonomic stability and transcendental meditation . Psychosom Med 1973 ; 35 (4) : 341–9 .

47. Travis F , Arenander A : Cross-sectional and longitudinal study of effects of transcendental meditation practice on interhemispheric frontal asym-metry and frontal coherence . Int J Neurosci 2006 ; 116 (12) : 1519 – 38 .

Dow


ic.oup.com/m




48. Travis FT , et al : Patterns of EEG coherence, power, and contingent neg-ative variation characterize the integration of transcendental and waking states . Biol Psychol 2002 ; 61: 293 – 319 .

49. Travis F , Tecce JJ , Guttman J : Cortical plasticity, contingent negative variation, and transcendent experiences during practice of the transcen-dental meditation technique . Biol Psychol 2000 ; 55 (1) : 41 – 55 .

50. Hebert R , et al : Enhanced EEG alpha time-domain phase synchrony during transcendental meditation: implications for cortical integration theory . Signal Process J 2005 ; 85: 2213 – 32 .

51. Travis FT : Autonomic and EEG patterns distinguish transcending from other experiences during Transcendental Meditation practice . Int J Psychophysiol 2001 ; 42 (1) : 1 – 9 .

52. Lyubimov NN : Changes in electroencephalogram and evoked potentials during application of a special form of psychological training (medita-tion) . Human Physiol (Fiziol Cheloveka) 1999 ; 25: 171 – 80 .

53. Yamamoto S , Kitamura Y , Yamada N , Nakashima Y , Kuroda S : Medial prefrontal cortex and anterior cingulate cortex in the generation of alpha activity induced by Transcendental Meditation: a magnetoencephalo-graphic study . Acta Med Okayama 2006 ; 60 (1) : 51 – 8 .

54. Dillbeck MC , Bronson EC : Short-term longitudinal effects of the Transcendental Meditation technique on EEG power and coherence . Int J Neurosci 1981 ; 14 (3–4) : 147–51 .

55. Alexander CN , Schneider RH , Staggers F , et al : Trial of stress reduction for hypertension in older African Americans: II. Sex and risk subgroup analysis . Hypertension 1996 ; 28 (2) : 228 – 37 .

56. Schneider RH , Alexander CN , Staggers F , et al : A randomized con-trolled trial of stress reduction in African Americans treated for hyper-tension for over one year . Am J Hypertens 2005 ; 18 (1) : 88 – 98 .

57. Jain S , et al : A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction . Ann Behav Med 2007 ; 33 (1) : 11–21 .

58. Gaylord C , Orme-Johnson D , Travis F : The effects of the Transcendental Meditation technique and progressive muscular relaxation on EEG coherence, stress reactivity, and mental health in black adults . Int J Neurosci 1989 ; 46 (1–2) : 77–86 .

59. Schneider RH , Alexander CN , Staggers F , Rainforth M , Salerno JW , Hartz A , et al : Long-term effects of stress reduction on mortality in per-sons > or = 55 years of age with systemic hypertension . Am J Cardiol 2005 ; 95 (9) : 1060 – 4 .

60. Alexander CN , Barnes V , Schneider RH , Langer EJ , Chandler HM , Davies JL : Randomized controlled trial of stress reduction on cardio-vascular and all-cause mortality in the elderly: results of 8 year and 15 year follow-ups . Circulation 1996 ; 93 (3) : 629 .

61. Rainforth MV , Schneider RH , Nidich SI , Gaylord-King C , Salerno JW , Anderson JW : Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis . Curr Hypertens Rep 2007 ; 9 (6) : 520 – 8 .

62. Alexander CN , Rainforth MV , Gelderloos P : Transcendental Meditation, self-actualization, and psychological health: a conceptual overview and statistical meta-analysis . J Soc Behav Pers 1991 ; 6 (5) : 189 – 247 .

63. Manzoni GM , et al : Relaxation training for anxiety: a ten-years system-atic review with meta-analysis . BMC Psychiatry 2008 ; 8: 41 .

64. Anderson JW , Liu C , Kryscio RJ : Blood pressure response to Transcendental Meditation: a meta-analysis . Am J Hypertens 2008 ; 21 (3) : 310 – 6 .

65. Nidich SI , et al : A randomized controlled trial on effects of the Tran-scendental Meditation program on blood pressure, psychological dis-tress, and coping in young adults . Am J Hypertens 2009 ; 22 (12) : 1326–31 .

66. Barnes VA , Treiber FA , Johnson MH : Impact of stress reduction on ambulatory blood pressure in African American adolescents . Am J Hypertens 2004 ; 17 (4) : 366 – 9 .

67. Barnes VA , Orme-Johnson DW : Clinical and pre-clinical applications of the Transcendental Meditation program in the prevention and treat-ment of essential hypertension and cardiovascular disease in youth and adults . Curr Hypertens Rev 2006 ; 2 (3) : 207 – 18 .

68. Schneider RH , Alexander CN , Wallace RK : In search of an opti-mal behavioral treatment for hypertension: a review and focus on Transcendental Meditation . In: Personality, Elevated Blood Pressure, and Essential Hypertension , pp 291–312 . Edited by EH Johnson , et al . Washington, DC , Hemisphere Publishing , 1992 .

69. Wenneberg SR , et al : A controlled study of the effects of the Transcendental Meditation program on cardiovascular reactivity and ambulatory blood pressure . Int J Neurosci 1997 ; 89 (1–2) : 15–28 .

70. Paul-Labrador M , Polk D , Dwyer JH , et al : Effects of a randomized con-trolled trial of Transcendental Meditation on components of the meta-bolic syndrome in subjects with coronary heart disease . Arch Int Med 2006 ; 166 (11) : 1218 – 24 .

71. De Armond D : Effects of the Transcendental Meditation program on psychological, physiological, behavioral and organizational conse-quences of stress in managers and executives . Dissertation Abstracts International 1996 ; 57 (6) : 4068B .

72. Walton KG , Schneider RH , Nidich SI : Review of controlled research on the Transcendental Meditation program and cardiovascular disease. Risk factors, morbidity and mortality . Cardiol Rev 2004 ; 12 (5) : 262 – 6 .

73. Walton KG , Schneider RH , Salerno JW , Nidich SI : Psychosocial stress and cardiovascular disease. Part 3: clinical and policy implications of research on the Transcendental Meditation program . Behav Med 2005 ; 30 (4) : 173 – 83 .

74. Walton KG , Schneider RH , Nidich SI , Salerno JW , Nordstrom CK , Merz CN : Psychosocial stress and cardiovascular disease. Part 2: effec-tiveness of the Transcendental Meditation program in treatment and prevention . Behav Med 2002 ; 28 (3) : 106 – 23 .

75. Alexander CN , Robinson P , Orme-Johnson DW , Schneider RH , Walton KG : The effects of Transcendental Meditation compared to other meth-ods of relaxation in reducing risk factors, morbidity, and mortality . Homeostasis 1994 ; 352: 243 – 64 .

76. Castillo-Richmond A , Schneider RH , Alexander CN , et al : Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans . Stroke 2000 ; 31 (3) : 568 – 73 .

77. Bowen S , Marlatt A : Surfi ng the urge: brief mindfulness-based inter-vention for college student smokers . Psychol Addict Behav 2009 ; 23 (4) : 666 – 71 .

78. Bowen S , et al : Mindfulness-based relapse prevention for substance use disorders: a pilot effi cacy trial . Subst Abus 2009 ; 30 (4) : 295 – 305 .

79. Leigh J , Bowen S , Marlatt GA : Spirituality, mindfulness and substance abuse . Addict Behav 2005 ; 30 (7) : 1335 – 41 .

80. Bowen S , et al : Mindfulness meditation and substance abuse in an incar-cerated population . Psychol Addict Behav 2006 ; 20 (3) : 343 – 7 .

81. Bowen S , et al : The role of thought suppression in the relationship between mindfulness meditation and alcohol use . Addict Behav 2007 ; 32 (10) : 2324 – 8 .

82. Hoppes K : The application of mindfulness-based cognitive interven-tions in the treatment of co-occurring addictive and mood disorders . CNS Spectr 2006 ; 11 (11) : 829 – 51 .

83. Royer A : The role of the Transcendental Meditation technique in pro-moting smoking cessation: a longitudinal study . Alcoholism Treatment Quarterly 1994 ; 11 (1–2) : 221–38 .

84. Haratani T , Henmi T : Effects of Transcendental Meditation on health behavior of industrial workers . Jap J Public Health 1990 ; 37: 729 .

85. Alexander CN , Robinson P , Rainforth MV : Treating and preventing alcohol, nicotine, and drug abuse through Transcendental Meditation: a review and statistical meta-analysis . Alcoholism Treatment Quarterly 1994 ; 11 (1–2) : 13 – 87 .

86. Gelderloos P , et al : Effectiveness of the Transcendental Meditation pro-gram in preventing and treating substance issue: a review . Int J Addict 1991 ; 26 (3) : 293–325 .

87. O’Murchu D : Spirituality, recovery, and Transcendental Meditation . Alcoholism Treatment Quarterly 1994 ; 11 (1–2) : 169–84 .

88. Klajner F , et al : Treatment of substance abuse by relaxation training: a review of its rationale, effi cacy and mechanisms . Addict Behav 1984 ; 9 (1) : 41–55 .

Dow


ic.oup.com/m




89. Carlson LE , et al : Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients . Psychoneuroendocrinol 2004 ; 29 (4) : 448–74 .

90. Calderon R , Schneider R , Alexander CN , Myers H , Nidich S , Haney C : Stress, stress reduction and hypercholesterolemia in African Americans and whites: a review . Ethn Dis 1999 ; 9: 451 – 62 .

91. Schneider RH , Nidich SI , Salerno JW , et al : Lower lipid peroxide levels in practitioners of the Transcendental Meditation program . Psychosom Med 1998 ; 60 (1) : 38 – 41 .

92. Infante JR , Torres-Avisbal M , Pinel P , et al : Catecholamine levels in practitioners of the Transcendental Meditation technique . Physiol Behav 2001 ; 72 (2) : 141 – 6 .

93. Bujatti M , Riederer P : Serotonin, noradrenaline, dopamine metabolites in Transcendental Meditation . J Neural Transm 1976 ; 39 (3) : 257–67 .

94. MacLean CR , Walton KG , Wenneberg SR , et al : Effects of the Transcendental Meditation program on adaptive mechanisms: changes in hormone levels and responses to stress after four months of practice . Psychoneuroendocrinol 1997 ; 22 (4) : 277 – 95 .

95. MacLean CR , Walton KG , Wenneberg SR , et al : Altered responses of cortisol, GH, TSH and testosterone to acute stress after four months’ practice of Transcendental Meditation (TM) . Ann N Y Acad Sci 1994 ; 746: 381 – 4 .

96. Jevning R , Wilson AF , Smith WR : The Transcendental Meditation tech-nique, adrenocortical activity, and implications for stress . Experientia 1978 ; 34 (5) : 618–9 .

97. Walton KG , Fields JZ , Levitsky DK , Harris DA , Pugh ND , Schneider RH : Lowering cortisol and CVD risk in postmenopausal women: a pilot study using the Transcendental Meditation program . Ann N Y Acad Sci 2004 ; 1032: 211 – 5 .

98. Glaser JL , Brind JL , Vogelman JH , et al : Elevated serum dehydroe-piandrosterone sulfate levels in practitioners of the Transcendental Meditation (TM) and TM-Sidhi programs . J Behav Med 1992 ; 15 (4) : 327 – 41 .

99. Wallace RK , Dillbeck MC , Jacobe E , Harrington B : The effects of the Transcendental Meditation and TM-Sidhi program on the aging pro-cess . Int J Neurosci 1982 ; 16 (1) : 53–8 .

100. Travis F , Haaga DA , Hagelin JS , et al : Effects of Transcendental Meditation practice on brain functioning and stress reactivity in college students . Int J Psychophysiol 2009 ; 71 (2) : 170 – 6 .

101. Appelle S , Oswald LE : Simple reaction time as a function of alertness and prior mental activity . Percept Mot Skills 1974 ; 38 (3) : 1263–8 .

102. Cranson RW , Orme-Johnson DW , Gackenbach J , Dillbeck MC , Jones CH , Alexander CN : Transcendental Meditation and improved perfor-mance on intelligence-related measures: a longitudinal study . Pers Indiv Differ 1991 ; 12: 1105–16 .

103. Holt WR , et al : Transcendental Meditation vs pseudo-meditation on visual choice reaction time . Percept Mot Skills 1978 ; 46: 726 .

104. Carroll D , Seers K : Relaxation for the relief of chronic pain: a system-atic review . J Adv Nursing 1998 ; 27 (3) : 476 – 87 .

105. Morone NE , Greco CM : Mind body interventions for chronic pain in older adults: a structured review . Pain Med 2007 ; 8 (4) : 359 – 75 .

106. Kabat-Zinn J : An outpatient program in behavioral medicine for chronic pain patients on the practice of mindfulness meditation: theoretical considerations and preliminary results . Gen Hosp Psychiatry 1982 ; 4: 33–47 .

107. Kabat-Zinn J , Lipworth L , Burney R : The clinical use of mindfulness meditation for the self-regulation of chronic pain . J Behav Med 1985 ; 8: 163–90 .

108. Kabat-Zinn J , Lipworth L , Burney R , Sellers W : Four year follow-up of a meditation based program for the self-regulation of chronic pain: treatment outcomes and compliance . Clin J Pain 1986 ; 2: 159–73 .

109. Smith BW , et al : A pilot study comparing the effects of mindfulness-based and cognitive-behavioral stress reduction . J Altern Complement Med 2008 ; 14 (3) : 251 – 8 .

110. Morone NE , et al : A mind-body program for older adults with chronic low back pain: results of a pilot study . Pain Med 2009 ; 10 (8) : 1395–407 .

111. Rosenzweig S , et al : Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home med-itation practice . J Psychosom Res 2010 ; 68 (1) : 29 – 36 .

112. Schmidt S , et al : Treating fi bromyalgia with mindfulness-based stress reduction: results from a 3-armed randomized controlled trial . Pain 2011 ; 152: 361 – 9 .

113. Mills WM , Farrow JT : The Transcendental Meditation technique and acute experimental pain . Psychosom Med 1981 ; 43: 157–64 .

114. Orme-Johnson DW , Schneider RH , Son YD , Nidich S , Cho Z-H : Neuroimaging of meditation’s effect on brain reactivity to pain . Neuroreport 2006 ; 17 (12) : 1359 – 63 .

115. Dixon C , Dillbeck MC , Travis F , et al : Accelerating cognitive and self development: longitudinal studies with preschool and elementary school children . J Soc Behav Pers 2005 ; 17 (1) : 65 – 91 .

116. Chandler HM , Alexander CN , Heaton DP : The Transcendental Meditation program post conventional self-development: a 10 year lon-gitudinal study . J Soc Behav Pers 2005 ; 17: 93 – 121 .

117. So KT , Orme-Johnson DW : Three randomized experiments on the holistic longitudinal effects of the Transcendental Meditation technique on cognition . Intelligence 2001 ; 29 (5) : 419 – 40 .

118. Kember P : The Transcendental Meditation technique and postgraduate academic performance . Brit J Educ Psychol 1985 ; 55: 164–6 .

119. Dillbeck MC : Meditation and fl exibility of visual perception and verbal problem solving . Mem Cognit 1982 ; 10 (3) : 207 – 15 .

120. Tanner MA , Travis F , Gaylord-King C , Haaga DAF , Grosswald S , Schneider RH : The effects of the Transcendental Meditation program on mindfulness . J Clin Psychol 2009 ; 65 (6) : 574 – 89 .

121. Jha AP , et al : Examining the protective effects of mindfulness training on working memory capacity and affective experience . Emotion 2010 ; 10 (1) : 54 – 64 .

122. Zeiden F , et al : Mindfulness meditation improves cognition: evidence of brief mental training. Conscious Cogn 2010; 19 (2) : 597 – 605 . Epub 2010 Apr 3 .

123. Chiesa A , et al : Does mindfulness training improve cognitive abilities? A systematic review of neurophysiological fi ndings . Clin Psychol Rev 2010 ; 31 (3) : 449 – 64 .

124. Travis FT : Creative thinking and the Transcendental Meditation tech-nique . J Creative Behav 1979 ; (13) : 169 – 80 .

125. Nidich SI : A study of the relationship of the Transcendental Meditation program to Kohlberg’s stages of moral reasoning (Doctoral Dissertation, University of Cincinnati) . Dissertation Abstracts International 1975 ; 36 (7) : 4361A .

126. Travis FT , Brown S : My brain made me do it: brain maturation and levels of self-development . In: The Postconventional Personality: Perspectives on Higher Development . Edited by Pfaffenberger AH , Marko PW , Greening T . New York , Sage Publishing , 2009 .

127. Nidich SI , Nidich RJ , Alexander CN : Moral development and higher states of consciousness . J Adult Development 2000 ; 7 (4) : 217 – 225 .

128. Nidich SI , Ryncarz RA , Abrams AI , Orme-Johnson DW , Wallace RK : Kohlbergian moral perspective responses, EEG coherence, and the Transcendental Meditation and TM-Sidhi program . J Moral Educ 1983 ; 12 (3) : 166–73 .

129. Gelderloos P , Hermans HJ , Ahlström HH , Jacoby R : Transcendence and psychological health: studies with long-term participants of the Transcendental Meditation and TM-Sidhi program . J Psychol 1990 ; 124 (2) : 177 – 97 .

130. Haratani T , Henmi T : Effects of Transcendental Meditation on mental health of industrial workers . Jap J Indus Health 1990 ; 32: 656 .

131. Hjelle JA : Transcendental Meditation and psychological health . Percept Mot Skills 1974 ; 39 (5) : 623–8 .

132. Seeman W , Nidich S , Banta T : Infl uence of Transcendental Meditation on a measure of self-actualization . J Counseling Psychol 1972 ; 19 (3) : 184–7 .

Dow


ic.oup.com/m




133. Kabat-Zinn J , Chapman-Waldrop A : Compliance with an outpatient stress reduction program: rates and predictors of completion . J Behav Med 1988 ; 11: 333–52 .

134. Miller J , Fletcher K , Kabat-Zinn J : Three year follow-up and clinical implications of a mindfulness-based stress reduction intervention in the treatment of anxiety disorders . Gen Hosp Psychiatry 1995 ; 17: 192–200 .

135. Kabat-Zinn J , Chapman A , Salmon P : The relationship of cognitive and somatic components of anxiety to patient preference for alternative relaxation techniques . Mind/Body Med 1997 ; 2: 101–9 .

136. Praissman S : Mindfulness based stress reduction: a literature review and clinician’s guide . J Am Acad Nurse Pract 2008 ; 20 (4) : 212 – 6 .

137. Allen NB , et al : Mindfulness-based psychotherapies: a review of con-ceptual foundations, empirical evidence and practical considerations . Aust N Z J Psychiatry 2006 ; 40 (4) : 285 – 94 .

138. Proulx K : Integrating mindfulness-based stress reduction . Holist Nurs Pract 2003 ; 17 (4) : 201 – 8 .

139. Rapgay L , Bystrisky A : Classical mindfulness: an introduction to its theory and practice for clinical application . Ann NY Acad Sci 2009 ; 1172: 148 – 62 .

140. Chiesa A , Serretti A : Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis . J Altern Complement Med 2009 ; 15 (5) : 593 – 600 .

141. Pipe TB , et al : Nurse leader mindfulness meditation program for stress management: a randomized controlled trial . J Nurs Adm 2009 ; 39 (3) : 130 – 7 .

142. Krisanaprakornkit T , et al : Meditation therapy for anxiety disorders . Cochrane Database Syst Rev 2006 ; (1) : CD004998 .

143. Chiesa A , Serretti A : Mindfulness based cognitive therapy for psychi-atric disorders: a systematic review and meta-analysis . Psychiatry Res 2011 ; 187 (3) : 441 – 53 .

144. Saeed SA , Antonacci DJ , Bloch RM : Exercise, yoga, and meditation for depressive and anxiety disorders . Am Fam Physician 2010 ; 81 (8) : 981 – 6 .

145. Toneatto T , Nguyen L : Does mindfulness meditation improve anxi-ety and mood symptoms? A review of the controlled research . Can J Psychiatry 2007 ; 52 (4) : 260–6 .

146. Tsang HW , et al : Effects of mindful and non-mindful exercises on people with depression: a systematic review . Br J Clin Psychol 2008 ; 47 (pt 3) : 303 – 22 .

147. Franco C , et al : Reducing teachers’ psychological distress through a mindfulness training program . Span J Psychol 2010 ; 13 (2) : 655–66 .

148. Martin-Asuero A , et al : The Mindfulness-based Stress Reduction pro-gram (MBSR) reduces stress-related psychological distress in health-care professionals . Span J Psychol 2010 ; 13 (2) : 897–905 .

149. Conrad A , Roth WT : Muscle relaxation therapy for anxiety disorders: it works but how? J Anxiety Disord 2007 ; 21 (3) : 243–64 .

150. Jorm AF , et al : Relaxation for depression . Cochrane Database Syst Rev 2008 ; (4) : CD007142 .

151. Dillbeck MC : The effect of the Transcendental Meditation technique on anxiety level . J Clin Psychol 1977 ; 33 (4) : 1076–8 .

152. Sheppard DH , et al : The effects of a stress management program in a high security government agency . Anxiety, Stress, and Coping 1997 ; 10 : 341 – 50 .

153. Fergusson LC , et al : Vedic science based education and nonverbal intel-ligence: a preliminary longitudinal study in Cambodia . J Instr Psychol 1995 ; (22) : 308 – 19 .

154. Grosswald SJ , Stixrud WR , Travis F , Bateh MA : Use of the Tran-scendental Meditation technique to reduce symptoms of Attention Defi cit Hyperactivity Disorder (ADHD) by reducing stress and anxiety: an exploratory study . Current Issues in Education [On-line] 2008 ; 10 (2) . Available at http://cie.ed.asu.edu/volume10/number2/.

155. Winbush NY , et al : The effect of mindfulness-based stress reduction in sleep disturbance: a systematic review . Explore (NY) 2007 ; 3 (6) : 585–91 .

156. Krystal AD : Treating the health, quality of life, and functional impair-ments in insomnia . J Clin Sleep Med 2007 ; 3 (1) : 63 – 72 .

157. Ljunggren G : The infl uence of Transcendental Meditation on neu-roticism, use of drugs and insomnia . Lakartidningen 1977 ; 74 (47) : 4212–4 .

158. Abrams AI , Siegel LM : The Transcendental Meditation program and rehabilitation at Folsom State Prison: a cross validation study . Criminal Justice and Behav 1978 ; 5: 3–20 .

159. Brooks JS , Scarano T : Transcendental Meditation in the treatment of post-Vietnam adjustment . J Counsel Dev 1985 ; 64: 212 – 5 .

160. Simpson TL , et al : PTSD symptoms, substance use, and vipassana med-itation among incarcerated individuals . J Trauma Stress 2007 ; 20 (3) : 239 – 49 .

161. Rosenthal J , Grosswald S , Ross R , Rosenthal N : Effects of Transcenden-tal Meditation in veterans of Operation Enduring Freedom and Opera-tion Iraqi Freedom with post traumatic stress disorder: a pilot study . Mil Med 2011 ; 176 (6) : 626 – 30 .

162. Chen ME : A comparative study of dimensions of healthy functioning between families practicing the TM program for fi ve years or for less than a year . J Holist Nurs 1987 ; 5 (1) : 6 – 10 .

163. Aron EN , Aron A : Transcendental Meditation and marital adjustment . Psychol Rep 1982 ; 51 (7) : 887–90 .

164. Alexander CN , Rainforth MV , Frank PR , Grant JD , Von Stade C : Walpole study of the Transcendental Meditation program in maximum security prisoners III: reduced recidivism . J Offender Rehabil 2003 ; 36 (1–4) : 161 – 80 .

165. Bleick CR , Abrams AI : The Transcendental Meditation program and criminal recidivism in California . J Criminal Justice 1987 ; 15: 211–30 .

166. Alexander CN , Orme-Johnson DW : Walpole study of the Transcendental Meditation program in maximum security prisoners II: longitudinal study of development and psychopathology . J Offender Rehabil 2003 ; 36 (1–4) : 127 – 60 .

167. Walton KG , Levitsky DK : Effects of the Transcendental Meditation program on neuroendocrine abnormalities associated with aggression and crime . J Offender Rehabil 2003 ; 36 (1–4) : 67 – 88 .

168. Anklesaria FK , King MS : The Enlightened Sentencing Project: a judi-cial innovation . J Offender Rehabil 2003 ; 36 (1–4) : 35 – 46 .

169. Barnes VA , Bauza LB , Treiber FA : Impact of stress reduction on nega-tive school behavior in adolescents . Health Qual Life Outcomes 2003 ; 1 (1) : 10 .

170. Suurkula J : Research on Transcendental Meditation at the Swedish Air Force . 2010 . Available at http://home.swipnet.se/tmdoctors/DMTeng.htm ; accessed January 4, 2011 .

171. Harung HS : Improved time management through human development: achieving most with least expenditure of time . J Manag Psychol 1998 ; 13 (5/6) : 406 – 28 .

172. Frew DR : Transcendental Meditation and productivity . Acad Manag J 1974 ; 17: 362–8 .

173. Harung H , Travis F , Blank W, Heaton D : Higher development, brain integration, and excellence in leadership . Management Decision 2009; 47 (6) : 872 – 94 .

174. McCollum B : Leadership development and self development: an empir-ical study . Career Dev Int 1999 ; 4 (3) : 149 – 54 .

175. Schmidt-Wilk J , Alexander CN , Swanson GC : Introduction of the Tran-scendental Meditation program in a Norwegian top management team . In Grounded Theory: 1984–1994 . Edited by Glaser B . Mill Valley, CA , Sociology Press , 2003 .

176. Schmidt-Wilk J : TQM and the Transcendental Meditation program in a Swedish top management team . The TQM Magazine 2003 ; 15 (4) : 219 – 29 .

177. Schmidt-Wilk J : Consciousness-based management development: case studies of international top management teams . J Transnat Manag Dev 2000 ; 5 (3) : 61 – 85 .

178. Schmidt-Wilk J , Alexander CN , Swanson GC : Developing conscious-ness in organizations: the Transcendental Meditation program in busi-ness . J Bus Psychol 1996 ; 10 (4) : 429 – 44 .

179. Broome JR , Orme-Johnson D , Schmidt-Wilk J : Worksite stress reduc-tion through the Transcendental Meditation program . J Soc Behav Pers 2005 ; 17 (1) : 235 – 76 .

Dow


ic.oup.com/m




180. Alexander CN , Swanson GC , Rainforth MV , Carlisle TW , Todd CC , Oates RM : Effects of the Transcendental Meditation program on stress reduction, health, and employee development: a prospective study in two occupational settings. Anxiety , Stress, & Coping 1993 ; 6: 245 – 62 .

181. Holeman R , Seiler G : Effects of sensitivity training and Transcen-dental Meditation on perception of others . Percept Mot Skills 1979 ; 49 (5) : 270 .

182. Hanley CP , Spates JL : Transcendental Meditation and social psycho-logical attitudes . J Psychol 1978 ; (99) : 121–7 .

183. Nidich SI , et al : Infl uence of Transcendental Meditation: a replication . J Counsel Psychol 1973 ; (20) : 565–6 .

184. Irving JA , et al : Cultivating mindfulness in health care professionals: a review of empirical studies of mindfulness based stress reduction (MBSR) . Complement Ther Clin Pract 2009 ; 15 (2) : 61 – 6 .

185. Bishop SR : What do we really know about mindfulness-based stress reduction? Psychosomatic Med 2002 ; 64 (1) : 71 – 83 .

186. Carlson CR , Hoyle RH : Effi cacy of abbreviated progressive mus-cle relaxation training: a quantitative review of behavioral medicine research . J Consult Clin Psychol 1993 ; 61 (6) : 1059 – 67 .

187. Glueck BC , Stroebel CF : Biofeedback and meditation and the treatment of psychiatric illness . Comprehensive Psychol 1975 ; (16) 4 : 413–4 .

188. Brown CT : Overcoming barriers to use of promising research among elite Middle East policy groups . J Soc Behav Pers 2005 ; (17) 1 : 489 – 543 .

189. Orme-Johnson DW , Alexander CN , Hawkins MA : Critique of the National Research Council’s report on meditation . J Soc Behav Pers 2005 ; 17 (1) : 383 – 414 .

190. Orme-Johnson DW , Barnes VA , Hankey AM , Chalmers RA : Reply to critics of research on Transcendental Meditation in the prevention and control of hypertension . J Hypertens 2005 ; 23 (5) : 1107 – 8 .

191. Duncan et al : Pilot study to gauge acceptability of a mindfulness-based, family focused preventive intervention . J Prim Prev 2009 ; 30 (5) : 605 – 18 .

192. Ottoson J-O : Swedish National Health Board Report on Transcendental Meditation . Socialstyrelesen D 1977 ; nr SN3_9_1194/73.

193. Herron RE : Can the Transcendental Meditation program reduce medi-cal expenditures of older people? A longitudinal medical cost minimi-zation study in Canada . J Soc Behav Pers 2005 ; 17 (1) : 415 – 42 .

194. Herron RE , Hillis SL : The impact of the Transcendental Meditation pro-gram on government payments to physicians in Quebec: an update—accumulative decline of 55% over a 6-year period . Am J Health Promot 2000 ; 14 (5) : 284 – 91 .

195. Orme-Johnson DW , Herron R : An innovative approach to reducing medical care utilization and expenditures . Am J Managed Care 1997 ; 3 (1) : 135 – 44 .

196. Herron RE , Hillis SL , Mandarino JV , Orme-Johnson DW , Walton KG : The impact of the Transcendental Meditation program on government payments to physicians in Quebec . Am J Health Promot 1996 ; 10 (3) : 208 – 16 .

197. Herron R , Schneider RH , Mandarino JV , Alexander CN , Walton KG : Cost-effective hypertension management: comparison of drug therapies with an alternative program . Am J Managed Care 1996 ; 2 (4) : 427 – 37 .

198. Orme-Johnson DW : Medical care utilization and the Transcendental Meditation program . Psychosomatic Med 1987 ; 49 (1) : 493 – 507 .

Dow


ic.oup.com/m


overview of outcome data of potential meditation training for

Documents